Title for Secure HIPAA Subscription Page

(This should be the name you advertise to the public. If none, leave blank.)
Title: (Dr., Mr., Mrs., Ms.)
(MD, OD, DDS, DO, PhD etc.)
(Therapeutic Optometrist, Board Certified, etc.)
(Dr. Smith, Ms. Jones, etc.- used with "appointment with Dr. Smith", etc.)
(Dr. James Smith, O.D. - This is for signing emails, notices. etc.)
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You may enter two office telephone numbers, including toll free numbers. Each number will be programmed to call up your secure Patient Form when a patient enters that number at SecurePatientRegistration.com or SecurePatientForms.com
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The email address below should be the email address where you want to be notified when a patient has completed one of your online Patient Forms. It should also be one that you can allow designated staff members to use if you intend to have your staff access and retrieve the completed patient forms. Staff members with access to the completed patient forms should be approved by your HIPAA Privacy Officer. This email address will not appear on your forms.
The email address below should be an email address where we can contact you. This email address will not appear on your form. It can be the same email address as above.
Your SecureHIPAA.com subscription includes the hosting of your Privacy Notice (with patient acceptance verification) and the secure Patient Registration form. These are all activated in their default configurations which refect the choices of 95% of SecureHIPAA.com subscribers. As soon as your account has been activated, you may make changes to your forms.
The SecureHIPAA.com Patient Registration Service is $49.50 monthly with no setup fee when paid annually.